AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 53, Summer 1999

Polarized and opposed opinions about the treatment of DID are voiced by many authorities; not surprisingly, mutually incompatible recommendations have been made about the conduct of its psychotherapy. Providing appropriate treatment under these circumstances can prove a daunting task. The difficulty is compounded because many aspects of relevant knowledge, such as dissociation, memory, cognitive psychology, social psychology (and others) are often complex fairly inaccessible to the nonspecialist. In this article I will present an overview of the psychotherapy of DID as it is described in the mainstream dissociative disorders and the psychiatric literature. I will address general principles rather than the details of "how to do it." I will not address the major controversies themselves, which are covered very well in the literature, from both the perspective of specialists in dissociative disorders (1-5), those skeptical of the legitimact of the dissociative disorders (6-9), and those who have attempted to assemble a diversity of views. However, I will discuss how a therapist might address controversial areas when they may impace upon the course of an ongoing treatment.

Within the dissociative disorder field, there is a general consensus that DID is a chronic, polysymptomatic, and postraumatic dissociative psychopathy caracterized by the presence of multiple identities (personality states or alters) and amnesia that requires for its definitive treatment a psychotherapy that conforms to the stage oriented treatment of trauma. In the treatment of the traumatized a stage in which safety is established is followed by a stage in which traumata are remembered and the effects of their impacts are grieved, and this is followed by a stage in which reconnections are made and recovery is achieved. These stages are called: safety, rememberance and mourning, and reconnection, respectively. These stages correspond well to larger numbers of stages described for the treatment of DID.

Establishing the psychotherapy aims for the creation of an empathic atmosphere of sagety, within which the security of the treatment frame can be forged, pragmatic arrangements for the treatment can be made, the theraputic alliance can be established, and the patience can be prepared for the therapy that will follow. This preperation involves discussion of the proposed treatment, its anticipated benefits and risks, an indication of alternative choices and their likely outcomes, a review of techniques likely to be employed along with their proposed benefits and drawbacks, and giving the patient appropriate cautions. The informed-consent process begins. Efforst are made to address the patients deprived but eventual achieved, persistent hope.

Preliminary interventions involve efforts to strengthen the patient as a whole and across alters in order to preserve and/or enhance the patients current level of functioning, estabilish the coping skills necessary to begin the difficult work that may follow, and to deal with any problems in the collaboration between the patient and the therapist. Access is gained to the more easily reached alters, agreements and contracts are established across as many alters as possible against interrupting the therapy abruptly, against suicide and self-harm, and against as many dysfunctional behaviors as the patient is ready and willing to curtail. Communication and cooperation among the alters is fostered, and increasing numbers of alters are brought into the therapeutic alliance. Further work is done with regard to the informed-consent process.

Whatever symptomatic relief can be offered will be offered, and techniques for coping with some of the disruptive symptoms of DID will be taught. Punitive superego attitudes and their enactment among the alters against on another are addressed. Guilt and shame management is a focus. The patient's psychodynamics, both as a whole, and within particular alters, are studied. Coping techniques play a valuable role in this stage, used not for undcovering, but in what are called temporizing techniques, designed to contain potentially disruptive material and affects, facilitate mastey and coping, and to prevent decompensation. They allow the treatment to titrate the amount of discomfort the patient must endure against his or her own resources and capacity to achieve mastery and self-efficacy. As the DID patient becomes able to use these techniques between sessions, they often allow the DID patient to feel for the first tiem that he or she can be effective rather than powerless in the face of the DID psychopathology and left events. For example, patients can be taught to substitute alters to stabilize the system, to create the subjective experience of sanctuary, to reduce the intensity whith which they experience distressing materials, to put upset alters to sleep between sessions, to sequester overwhelming material between sessions, to break intense experiences into less overwhelming ones, and to reconfigure their alter system to effect coping that does not involve dysfunctional or self-destructive behavior. Clearly some of the activities of stage 1 and 2 overlap.

History gathering and mapping investigates the alters in depth. Now with the patient strengthened, it becomes possible to proceed to history gathering and mapping during which the therapist learns more about the personalities, their origins, their concerns, and their relationships to one another. The inner world of the DID patient, in which the alters interact governed by a uniques series of rules and in relationships that often reenact family constellations or particular experiences, is explored. The therapist comes to beter appreciate the unique issues and perspectives of the personalities, and to understand how the alter system responds to particular issues or stressors. With this knowledge, the therapist uses the tools established in stages 1 and 2 to address problems experienced by particular alters and in the function of the system, and presses for still more cooperation and collaboration. Many experts feel that is is dangerous to progress into work on traumatic material without first getting "the lay of the land," and being able to anticipate how the system will react to dealing with traumata. For example if mapping demonstrates that there are many alters with related concerns, the therapist can anticipate that active efforst to deal with the concerns of any one of these alters may mobilize the others as well, and may wish to use techniques to reduce the likelihood that this will occur (e.g., by using hypnosis to distract or put to sleep all alters with similar concerns while one is being treated). Without such advance knowledge, ther therapist who believes that he or she is addressing the issues one particular alter might suddently be confronted with an unanticipated crisis as many alters of which he or she is unaware begin simultaneous abreactions (flashbacks). In the model of tactical integrationalism proposed which whill be addressed latter, mapping allows the therapist to indentify and work with alters who share many similarities and affiliations in a manner that minimizes the disuption of the alter who carry on daily life activities.

Metabolism of the trauma involves the interventions associated with accessing and processing the overwhelming events associated with the origins or the maintenance of the DID patient's psychopathology. It is useful to remind the patient that the material to be addressed will processed in the interests of the patient's recovery, and that neither the feelings associated with the material nor the sense of relief experienced after it has been addressed is evidence of its historical veridicality. It is not to all unusual for the conduct of this of earlier stages, because an unrelenting focus on trauma work can be counter productive for the stability and well-being fo the DID patient. Many clinicians use a variety of techniques to facilitate the management of this stage. Hypnosis offers many opportunites to moderate and modulate trauma work, and Eye Movement Densensitization and Reprocessing (EMDR) finds a role in many treatments. Both hypnosis and EMDR make it possible to fractionate the management of trauma work. In fractionation techniques, a model of abreaction (flashbacks) more anaologeous to implosion of flooding. Fractionated work (described below) is less likely to prove overwhelming to the patient, and make this stage of therapy more gentle and manageable.

Whatever material is represented as traumatic must be addressed in order to move toward full intergration, whether or not it appears to be historically accurate. However, whenever possible, it is useful to address the more credible material first, retaining the material that gives the appearance of being most unlikely until later. In some situations the entire DID situatoin becomes resolved before it is addressed; in some, it is processed much more easily later, evin if it is more striking an repugnant; in some, the patient, is processing the more credible material, concludes that the less credible material was a form of screen for it, and it never needs to be addressed per se; and in some instances the less credible material will require strenuous processing, but the patient will have achieved so much mastery before it is addressed that its management will be less disruptive than it otherwise would have been.

Moving toward integration/resolution is a stage in which efforts are made to achieve the working through of the traumatic material across all of the alters, and to encourage still more cooperation, communication, mutual empathy, and indentification across alters. As these efforts progress, and inner conflicts are increasingly reduced, it is not unusual for the alters to begin to show some blurring of their characterists, some fading of their prominence, and some identity confusion. Often the therapist will be confronted with alters who are not sure who they are, or who experience themselves as copresent with other alters.

Integration/resolution consists of the patient's coming to a workable stance, either as a single personality or as a stable collaboration of alters toward both self and the world. A smooth collaboration is a resolution; the alters' blending into a unity is an integration. Follow-up research suggests that integration is a preferable outcome, but some patients resist taking this final step.

Learning new coping skills, of course, has gone on throughout the therapy, but now becomes a major focus as the patient needs help in negotiating circumstances in a more constructive way that once were managed in a dissociative manner. Many important life decisions and relationships now seen without the obstructions and distortions imposed by dissociation, may require reevaluation, and both alternative problem-solving and life changes may be the outcome

Solidification of gains and working through may prove a long process. The DID patient must learn how to live in the world using alternatives to dissociative coping, and often working through transference issues in the therapy allows more solid mastery of the issues stemming from their traumata and past experiences. Characterologic issues that may have been hidden or camouflaged by dissociative symptoms may require attention, and often extensive coaching on the management of relationships and intercurrent traumata proves necessary.

Follow-up involves the assessment of stability and prevention against relapse, which is especially important for patients who elect resolution rather than integration. Also, additional layers of alters may be encountered, and aspects of recovery that were more flight into health than substantial improvement may require attention.

This model is consistent with a treatment approach that is designed to bring about the complete resolution of DID psychopathology. However, patients are encountered (and will be discussed at length below) who are not candidates for such treatment. They fail to progrest with this model, or prove unable to tolerate work with traumatic material. Such patients do better with a supportive treatment that aims to decrease their discomfort, retain their augment level of function, and facilitate their coping with everday life and relationship issues. The alters indeed will have to be addressed, but efforts with them will focus on their more appropriate cooperation and collaboration to deal with the patient's here-and-now concerns. Efforts will be made not to impose the additional burden of uncovering and dealing with traumatic and possibly disruptive materials. These will be addressed only if they intrude and cannot be set aside. Integration will not be a goal. Attempts to treat such patients as if they were candidates for definitive treatment are likely to cause them great distress and make it more difficult for them to cope. The treatment of this group of DID patients is less familiar and has not been addressed in the literature until recently, but it is one of the most important areas of concern in the treatment of DID. Often their entire therapy consists of efforts to achieve the goals of the first two stages of DID treatment; it remains the stage of safety.

Now let us return to the three-stage model and match its components to the nine-stage DID treatment. In the definitive model described above, DID treatment stages 1 and 2 are consistent with (Herman's) first stage, safety. DID treatment stage 4 correlates with (Herman's) second stage, rememberance and mourning. DID treatment stages 5-9 mirror (Hermans) third stage, reconnection. But what of the DID treatment stage 3, history and mapping? In the definitive treatment of DID, it is primarily a part of (Herman's) stage of safety, since it lays the ground-work for the trauma work. The mapping and the work with individual alters' issues in a preliminary way serves this purpose. However, its history-gathering component is uncovering, and uncovering may occure in the process of mapping. Therefore, if a decision is made not to progress to a definitive treatment designed to completely resolve DID, the clinician should consider history gathering and mapping to have aspects that may or may not be appropriate in a given case. Therefor, in a supportive treatment, DID treatment stage 3 often is better understood as affiliated, along with the DID treatment stage 4, with (Herman's) stage of remembrance and mourning.

THE SPECTRUM OF STANCES OR APPROACHES TO THE TREATMENT OF DID

Beyond matters of theoretical orientation and the selection of techniques, the stance of approach to treatment taken by the therapist (and at times by the patient) plays a major role in what can and will transprire. Although many therapists in past years approached the treatment of DID as if it were inevitably a wild and out-of-control process, desperately applied technique after technique trying to find something that worked, or tried to force the psychotherapy of DID treatment paradigm with which they were already familiar, the approaches have not proven effective. In each case they treat, current practitioners knowledgeable about DID implicitly or explicity embrace one of the following stances: strategic intergrationalism, tactical integrationalism, personality-oriented treatment, adaptationalism, or minimization.

Strategic Integrationalism
Strategic Intergrationalism is the attempt to treat DID in a psychotherapy that is consistent with the psychoanalytic tradition of resolving pathological defenses and structures and facilitating growth and development. From this stance the therapist generally attempts to create an atmosphere supportive of a process-oriented psychotherapy. Its goal is the integration of the personalities in the course of recovery of the individual DID patient. Whatever additional techniques and specialized interventions may be employed in the course of treatment are valued less for themselves than than for the long term goals to which they contribute. This approach focuses on rendering the dissociative defenses and structures that sustain DID less viable, so that the condition collapses from within. Its idea goal is the integration of the personality in the course of the overall resolution of the patients symptoms and difficulties of living.

Tactical Integrationalism
Tactical integrationalism emphasizes the skillful orchestration and application of techniques in the service of attaining a series of discrete goals that lead to the superordinate goal of integration and recovery. This stance espouses the same ideal outcome as strategic integrationalism, the integration of the personalties, but the actual conduct of the therapy reveals a predominant concentration on tactics, and on discrete interventions that serve as adroit devices to accomplish a series of objectives....Their planfulness and deliberateness may be conspicuous. At times these therapies take the form of a series of short-term therapies within the context of a long-term therapy. Many interventions from many schools of therapy may be applied. Process is appreciated, but it is understood to be the context in which the therapist applies interventions which themselves are major vehicle of the treatment, and cognitive therapy. Such approaches stem from the traditions of hypnosis, behavior therapy, and cognitive therapy. Personality-Oriented Psychotherapy Certain therapist do not regard dividedness per se as problematic. Their approaches often involve a problem-solving inner-group therapy or inner-family therapy among the alters. Smoother collaboration is encouraged to effect a more harmonious and functional arrangement among the alters. Integration may or may no be pursued.

This term has also been used to describe an approach in which the alters are understood to be genuine people who must be nurtured into health in a very tangible way. Although occasionally successful, many unfortunate outcomes have been noted. The latter approach is contraindicated.

Adaptationalism
This approach prioritizes the management of life activities and the maintenance and improvement of function over integration. It avoids concentration on trauma work or uncovering. It stems from the traditions of supportive psychotherapy. This is a suitable approach when a definitive treatment is contraindicated, but, since it have the potential to deprive a patient who is capable of in a definitive treatment of the chance to make a full recovery, its use with such patients would appear to be innappropriate.

Minimization
This approach generally proceeds from the assumption that DID is not a genuine clinical phenomenon, and embraces the premise that if the manifestations of DID are not reinforced with attention, they will cease to appear. This approach is widely endorsed, mostly by those skeptical about DID, but has not demonstrated widespread clinical utility. In fact, unpublished data acquired in conjunction with a naturalistic longitudinal study of DID patients demonstrated that every DID patient treated in this manner continued to have DID on follow-up. At the most, this approach had temporarily suppressed its manifestations.

While most therapies are dominated by one of the above stances, the circumstances and stability of DID patients in treatment may vary considerably over time, and require flexible transitions from one stance to another to address particular situations. For example, a mother with DID in a therapy characterized by an exploratory strategic intergrationalist stance who is suddenly confronted with the serious illness of her child may profit from a transition to a personality-oriented or adaptationalist therapy while her energy must be diverted from her treatment to the care of her child. The complete resolution of DID psychopathology can be achieved from the stances of strategic integrationalism, tactical integrationalism, and personality-oriented treatment. It cannot be achieved from the stances of adaptationalism or minimization. The supportive psychotherapy of DID is incompatible with the full application fo the strategic intergrationalist or tactical integrationalist stance, although these may be adapted and modified for the supportive purposes. Personality-oriented treatment and adaptationalism are compatible with the supportive treatment of DID. Minimization as an overall therapeutic stance is rarely indicated. Later in this article the matching of therapeutic stances to patient characteristics and therapeutic goals will be addressed further.